CLINICAL AUDIT

BLOOD WASTAGE IN PATIENTS

(Jan 2018 to June 2018
 AIM
• TO KNOW AND REDUCE BLOOD UNITS
WASTED
 PURPOSE

• To reduce the number of blood units wastage

to nil
 scope
• All patients who underwent and planned for
blood transfusion in the hospital
 Name of auditors
• Dr ROHIT BHANOT (MEDICAL DIRECTOR)

• MRS.RAVINDRA KAUR (NURSING INSTRUCTOR)

• Mr. NAVDEEP GAURI (NURSING SUPERINTENDENT)

• Miss. ANKITA SETIA (I.C.N.)

 Duration of clinical audit
• 6 months
 INTRODUCTION

Blood is a valuable resource and blood wastage in a

low socio economic country could impose a very
serious impact on healthcare. This study therefore
analyzes the usage and wastage of blood and blood
products at the AADHAR HOSPITAL HISAR.
 METHOD
• This clinical audit has been basically
conducted by reviewing blood transfusion
usage and wastage data of hospital
retrospectively from Jan 2108 to May 2018

• Proposed recommendation or suggestion have

been incorporated so as to improve our
practice and re audited after one month to
see the change on July2018
 DISCUSSION
Blood and its components are very significant for human life and
therefore blood transfusion can be a life-saving intervention.
There are multiple factors that contribute to shortfall in provision of
blood including deficient donor recruitment, poor stock management
and transportation The demand for blood surpasses the blood supply
in many countries World Health Organization (WHO) data indicated
that 87.5 % of developing countries collect less than half of the blood
needed to meet the transfusion requirements of their populations
Studies on developing countries reported that most of the limited
blood supplies are used for complications of pregnancy
and childbirth, trauma and severe anemia in childhood
 DISCUSSION
Many factors lead to wastage of blood products like broken bag, broken seal,
expired units, returned after 30 min, clotted blood or miscellaneous reasons
which is most importantly due to lack of proper knowledge and awareness.
According to the “30-minute rule” and guidelines for blood transfusion in the
UK recommend that if RBC units are out of controlled temperature storage
for more than 30 min, they should not be put back into storage for reissue.
The justification for this rule is that once RBC units are out of controlled
temperature storage, the component warms up, and the risk of bacterial
proliferation increases with time
 DISCUSSION
Hospital system on blood transfusion

At AADHAR HOSPITAL ,blood collection, processing and screening blood

from donors is done at the blood banks at MANGLAM DIAGNOSTICS and
SARVODAYA BLOOD BANK . It is centralized blood center which collects
blood directly or through blood center which collects blood directly or
through blood drives from voluntary blood donors.

We send individualized requests for blood to these blood banks and

blood is arranged or issued as per requirement.

All data collected for blood requests and wastage was processed and
categorized as follows
1. Total no of blood and blood products ordered
2. comparative utilization of blood products
3. Total no of wastage of blood products
4. Reasons for wastage of blood products
FINDINGS
 NO. OF BLOOD PRODUCTS ISSUED MONTH WISE

NO. OF BLOOD & BLOOD PRODUCTS ISSUED (JANUARY TO JUNE 2018)

TYPE OF
BLOOD JANUARY FEBRUARY MARCH APRIL MAY JUNE
WHOLE
BLOOD 22 13 8 9 20 4
PCV 2 0 3 1 0 0
PRBC 23 30 121 74 94 101
FFP 74 50 50 42 75 61
PLATELETS 0 3 1 8 13 10
CRYO 0 0 0 0 0 0
BLOOD WASTAGE

MONTH PERCENTAGE
JANUARY 4%
FEBRUARY 0%
MARCH 5%
APRIL 4%
MAY 2%

PERCENTAGE OF WASTAGE OF BLOOD

100%
80%
60%
40%
20% 4% 5% 4% 2%
0% PERCENTAGE
0%
 BLOOD WASTAGE AMONG DIFFERENT CATEGORIES(JANUARY TO MAY)

TYPE OF BLOOD PERCENTAGE

WB 18%
PCV 0%
PRBC 1%
FFP 0%
PLATELETS 0%
CRYO 0%

DIFFERENT CATEGORIES OF BLOOD WASTAGE

100%
80%
60%
40%
18%
20% 0% 1% 0% 0% 0% PERCENTAGE
0%
REASONS FOR BLOOD WASTAGE

• In Surgery department in 15 Patients blood was

arranged expecting the blood loss during
surgery and not given as surgeries were blood
less.

• In 5 cases patients has minor blood reaction so

blood was not given.

• In 6 cases patients was expired during the

course of treatment leading to blood wastage
 OBSERVATIONS
• Main reason for blood wastage was found to be
in elective major surgeries where blood was
issued suspecting blood loss.
• There were no guidelines followed for arranging
and issuing blood
• Whole blood was the main component which was
wasted most of time.
• Major contributing factor could be the absence
of blood bank or blood storage unit within the
hospital premises
 RECOMMENDATIONS
1) Guidelines for blood and blood products transfusion to be implemented
hospital wide for judicious use of blood as per the N.I.C.E. Guidelines

2) Restrictive threshold level for blood transfusion to be followed to avoid

unnecessary ordering

3) Alternative methods to blood and blood products transfusion were framed to

avoid blood transfusion

3) Awareness program regarding preciousness of blood and blood products is done

to sensitize Doctors and Staffs

4) Recommendation to have blood bank in the hospital premises is conveyed to

Hospital management
 GUIDELINES
1.1 Alternatives to blood transfusion for patients having surgery

Erythropoietin

1:Do not offer erythropoietin to reduce the need for blood transfusion in patients
having surgery, unless:

the patient has anemia and meets the criteria for blood transfusion, but declines
it because of religious beliefs or other reasons or
the appropriate blood type is not available because of the patient's red cell
antibodies.
 GUIDELINES
Intravenous and oral iron

1 Offer oral iron before and after surgery to patients with iron-deficiency
anemia.

2. Consider intravenous iron before or after surgery for patients who:

have iron-deficiency anemia and cannot tolerate or absorb oral iron, or are
unable to adhere to oral iron treatment (see the NICE guideline )
are diagnosed with functional iron deficiency
are diagnosed with iron-deficiency anemia, and the interval between the
diagnosis of anemia and surgery is predicted to be too short for oral iron to be
effective.
 GUIDELINES
Cell salvage and Tranexamic acid

1: Offer Tranexamic acid to adults undergoing surgery who are expected to

have at least moderate blood loss (greater than 500 ml).

2: Consider Tranexamic acid for children undergoing surgery who are expected
to have at least moderate blood loss (greater than 10% blood volume).

3: Do not routinely use cell salvage without Tranexamic acid.

4: Consider intra-operative cell salvage with Tranexamic acid for patients who
are expected to lose a very high volume of blood (for example in cardiac and
complex vascular surgery, major obstetric procedures, and pelvic
reconstruction and scoliosis surgery).
 RESTRICTIVE THRESHOLD
1.2 Red blood cells
Thresholds and targets
1.2.1 Use restrictive red blood cell transfusion thresholds for patients who need red blood
cell transfusions and who do not: have major haemorrhage or
have acute coronary syndrome or need regular blood transfusions for chronic anemia.
1.2.2 When using a restrictive red blood cell transfusion threshold, consider a threshold of
7 g/dl and a haemoglobin concentration target of 7–9 g/dl after transfusion.
1.2.3 Consider a red blood cell transfusion threshold of 8g/litre and a haemoglobin
concentration target of 8–10 g/DL after transfusion for patients with acute coronary
syndrome.
1.2.4 Consider setting individual thresholds and haemoglobin concentration targets for
each patient who needs regular blood transfusions for chronic anemia.

Doses
1.2.5 Consider single-unit red blood cell transfusions for adults (or equivalent volumes
calculated based on body weight for children or adults with low body weight) who do not
have active bleeding.
1.2.6 After each single-unit red blood cell transfusion (or equivalent volumes calculated
based on body weight for children or adults with low body weight), clinically reassess and
check haemoglobin levels, and give further transfusions if needed.
1.4 Fresh frozen plasma
Thresholds and targets
1.4.1 Only consider fresh frozen plasma transfusion for patients with clinically
significant bleeding if they have abnormal coagulation test results (for
example, prothrombin time ratio or activated partial thromboplastin time ratio above
1.5).
1.4.2 Do not offer fresh frozen plasma transfusions to correct abnormal coagulation in
patients who:
are not bleeding (unless they are having invasive procedures or surgery with a risk of
clinically significant bleeding)
need reversal of a vitamin K antagonist.
1.4.3 Consider prophylactic fresh frozen plasma transfusions for patients with
abnormal coagulation who are having invasive procedures or surgery with a risk of
clinically significant bleeding.
Doses
1.4.4 Reassess the patient's clinical condition and repeat the coagulation tests after
fresh frozen plasma transfusion to ensure that they are getting an adequate dose, and
give further doses if needed.
1.3 Platelets

Thresholds and targets

Patients with thrombocytopenia who are bleeding

1.3.1 Offer platelet transfusions to patients with thrombocytopenia who have clinically
significant bleeding (World Health Organization [WHO] grade 2) and a platelet count below
30×109 per liter.
1.3.2 Use higher platelet thresholds (up to a maximum of 100×109 per liter) for patients with
thrombocytopenia and either of the following:
severe bleeding (WHO grades 3 and 4)
bleeding in critical sites, such as the central nervous system (including eyes).

Patients who are not bleeding or having invasive procedures or surgery

1.3.3 Offer prophylactic platelet transfusions to patients with a platelet count below
10×109 per liter who are not bleeding or having invasive procedures or surgery, and who do not
have any of the following conditions:

chronic bone marrow failure

autoimmune thrombocytopenia
heparin-induced thrombocytopenia
thrombotic thrombocytopenic purpura.
Patients who are having invasive procedures or surgery
1.3.4 Consider prophylactic platelet transfusions to raise the platelet count
above 50×109 per litre in patients who are having invasive procedures or
surgery.
1.3.5 Consider a higher threshold (for example 50–75×109 per litre) for patients
with a high risk of bleeding who are having invasive procedures or
surgery, after taking into account:
the specific procedure the patient is having
the cause of the thrombocytopenia
whether the patient's platelet count is falling
any coexisting causes of abnormal haemostasis.
1.3.6 Consider prophylactic platelet transfusions to raise the platelet count
above 100×109 per liter in patients having surgery in critical sites, such as the
central nervous system (including the posterior segment of the eyes).
When prophylactic platelet transfusions are not indicated
1.3.7 Do not routinely offer prophylactic platelet transfusions to patients with any
of the following:
chronic bone marrow failure
autoimmune thrombocytopenia
heparin-induced thrombocytopenia
thrombotic thrombocytopenic purpura.
1.3.8 Do not offer prophylactic platelet transfusions to patients having procedures
with a low risk of bleeding, such as adults having central venous cannulation or any
patients having bone marrow aspiration and trephine biopsy.
Doses
1.3.9 Do not routinely transfuse more than a single dose of platelets.
1.3.10 Only consider giving more than a single dose of platelets in a transfusion for
patients with severe thrombocytopenia and bleeding in a critical site, such as the
central nervous system (including eyes).
1.3.11 Reassess the patient's clinical condition and check their platelet count after
each platelet transfusion, and give further doses if needed.
 REAUDIT

Re audit was done for the month of June

 REAUDIT FINDINGS

No of blood products issued in JUNE : 175

No and type of blood products wasted: 1 PRBC

1 FFP

% Of blood products wasted : 1.1 %

 CONCLUSION

After sensitization of consultants and concerned staff and

Implementation of new guidelines our data for blood transfusion
showed improved trend.

We were able to reduce our wastage significantly but

could not be brought down to nil.

More scrutinized approach has to be followed in future to reach

our goal of nil blood wastage as per ideal practice standard